Seminars in Neurology最新文献

Clinical informatics (CI) is an emerging field within biomedical informatics that sits at the intersection of clinical care, health systems, and health information technology (IT). CI emphasizes how individuals (neurologists, patients, staff) interact with health IT (HIT), with a focus on designing systems that support optimal neurologic care. As neurology becomes more complex-expanding diagnostics, treatments, and subspecialties-there is a growing need for usable, efficient electronic health record systems that enhance, rather than burden, care delivery. This paper reviews roles CI neurologists can play, as translators, architects, advocates, and leaders across clinical, operational, and strategic domains. We highlight examples where CI expertise addresses challenges in neurology, including access to care, documentation burden, burnout, quality improvement, patient engagement, artificial intelligence, research registries, and precision health. With projected workforce shortages in neurology and CI, neurologists with CI expertise will ensure that HIT will effectively support high-quality neurologist-led care.

Neurologists engaged in meaningful and satisfying work are positioned to advance the field through research, education, and patient care. On the other hand, neurologists are at elevated risk for burnout and career dissatisfaction, influenced by personal characteristics but driven primarily by external factors at work unit, organizational, and systemic/societal levels. Recognizing and attending to the full range of factors that influence neurologist well-being is necessary to avoid detrimental consequences on patients, clinicians, organizations, and public health. This discussion will review the current state of well-being in neurology, explore drivers and outcomes, and present strategies for improving career satisfaction.

Neurologists in ambulatory settings struggle with low appointment availability and increased work related to patient care outside of clinic visits. Neurologists can better meet these demands using asynchronous or non-face-to-face care options. Specific billing codes allow reimbursement for work neurologists are already doing to care for their patients between visits. This includes care delivery over patient portal messages (e-visits), asynchronous consultations through the electronic health record (EHR) system requested by providers for their patients with neurologic issues (eConsults), care coordination and record review outside of clinic visits (prolonged service for non-face-to-face care outside of the date of service and transitional care management), and analyzing data from new technologies and devices for patient diagnosis and therapeutic monitoring (remote patient monitoring). Artificial intelligence shows promise to improve how neurologists deliver asynchronous care. More seamless incorporation of asynchronous care options in the EHR and clinic templates will ultimately be necessary to improve neurologists' efficiency and work-life balance.

Artificial intelligence (AI) has emerged as a transformative force in the management of movement disorders. This review explores the various applications of AI across the spectrum of care, from diagnosis to clinical workflows, treatment, and monitoring. Recent advancements include deep phenotyping tools like the Next Move in Movement Disorders (NEMO) project for hyperkinetic disorders, diagnostic platforms such as DystoniaNet, and biomarker identification systems for early Parkinson's disease detection. AI may revolutionize treatment selection through technologies like DystoniaBoTXNet and adaptive deep brain stimulation systems. For symptom monitoring, innovations like the Emerald device and smartphone-based assessment tools enable continuous, objective evaluation. AI may also enhance patient care through improved telemedicine capabilities and ambient listening. Despite these promising developments, recent critiques highlight methodological concerns in AI research, emphasizing the need for rigorous validation and transparency. The future of AI in movement disorders requires balancing technological innovation with clinical expertise to improve patient outcomes.

Insomnia is highly prevalent in clinical practice and can present independently or alongside other medical and mental health disorders. Insomnia is a risk factor for the development and exacerbation of medical and mental health conditions. Behavioral and pharmacological treatments for insomnia are available. In this article, we review important mechanisms associated with insomnia including the hyperarousal model of insomnia and the neurobiology of insomnia. We then review the treatment approaches and management strategies for insomnia including cognitive behavioral therapy for insomnia, transcranial magnetic stimulation, pharmacologic treatment, and adjunctive treatments for insomnia.

Circadian rhythms (CRs) are entrainable endogenous rhythms that respond to external stimuli and regulate physiological functions. The suprachiasmatic nucleus (SCN) in the hypothalamus is the mammalian master clock that synchronizes all other tissue-specific peripheral clocks, primarily through gamma-aminobutyric acid (GABA) and vasoactive intestinal polypeptide (VIP). The SCN follows Earth's 24-hour cycle by light entrainment through the retinohypothalamic tract. At the cellular level, the core clock genes CLOCK, BMAL1, PER1-PER3, CRY1, and CRY2 regulate CRs in a negative feedback loop. The circadian disruption of the sleep-wake cycle manifests in at least six distinct clinical conditions. These are the circadian rhythm sleep-wake disorders (CRSWDs). Their diagnosis is made by history, sleep diaries, and actigraphy. Treatment involves a combination of timed light exposure, melatonin/melatonin agonists, and behavioral interventions. In addition, CR disturbances and subsequent misalignment can increase the risk of a variety of illnesses. These include infertility and menstrual irregularities as well as diabetes, obesity, fatty liver disease, and other metabolic syndromes. In addition, a disruption in the gut microbiome creates a proinflammatory environment. CR disturbances increase the risk for mood disorders, hence the utility of light-based therapies in depression. People with neurodegenerative disorders demonstrate significant disturbances in their CRs, and in their sleep-wake cycles. Circadian realignment therapies can also help decrease the symptomatic burden of these disorders. Certain epilepsy syndromes, such as juvenile myoclonic epilepsy (JME), have a circadian pattern of seizures. Circadian disturbances in epilepsy can be both the consequence and cause for breakthrough seizures. The immune system has its own CR. Disturbances in these due to shift work, for instance, can increase the risk of infections. CR disturbances can also increase the risk of cancer by impacting DNA repair, apoptosis, immune surveillance, and cell cycle regulation. Moreover, the timing of chemotherapeutic agents has been shown to increase their therapeutic impact in certain cancers.

Sleep disturbances and cognitive decline are intricately connected, and both are prevalent in aging populations and individuals with neurodegenerative disorders such as Alzheimer's disease (AD) and other dementias. Sleep is vital for cognitive functions including memory consolidation, executive function, and attention. Disruption in these processes is associated with cognitive decline, although causal evidence is mixed. This review delves into the bidirectional relationship between alterations in sleep and cognitive impairment, exploring key mechanisms such as amyloid-β accumulation, tau pathology, synaptic homeostasis, neurotransmitter dysregulation, oxidative stress, and vascular contributions. Evidence from both experimental research and population-based studies underscores the necessity of early interventions targeting sleep to mitigate risks of neurodegenerative diseases. A deeper understanding of the interplay between sleep and cognitive health may pave the way for innovative strategies to prevent or reduce cognitive decline through improved sleep management.

Excessive daytime sleepiness (EDS) is common. However, clinical features of excessive sleepiness can have broad and variable presentations. In addition, there can be an increased likelihood of medical or psychiatric comorbidity. Examination of the networks that regulate sleep-wake and circadian control reveals a complex and intricately designed integration system. Dysregulation in the coordination, effectiveness, or efficiency of these systems can contribute to developing EDS, and inform on the endotypes observed and pharmacologic considerations for treatment. The discovery and characterization of the diurnal expression and function of orexin (hypocretin) have led to a transformed understanding of sleep-wake control and EDS, as well as its role beyond sleep. As a result, a novel drug class, orexin agonists, is anticipated to emerge for clinical use in the near future. An understanding of orexin physiology and its transdisciplinary impact is necessary to best prepare for patient selection, use, and anticipated benefit and monitoring of both expected benefits and any other health change. This study provides a review of the range of clinical features and impact of EDS, the relationship between sleep-wake, circadian and other health networks, and an examination of orexin physiology with anticipatory guidance on the potential transdisciplinary role and impact of orexin agonists.